# Acute rheumatic fever with carditis - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: Acute Rheumatic Fever - StatPearls - NCBI Bookshelf - https://www.ncbi.nlm.nih.gov/books/NBK459263/ · ICPC-3 (WONCA International Classification of Primary Care, 3rd edition) class KD02.00 - condition scope only, no dose · No dose - referral pathway, no medicine given in primary care - Verified date: 2026-08 ## Verified against - No dose - referral pathway, no medicine given in primary care - Egyptian National Drug Formulary - Antimicrobial 2023 ## Treatment metadata - No drug therapy in primary care (Referral & Advice) - Penicillin G benzathine — injection ## Complete treatment card ```text ACUTE RHEUMATIC FEVER WITH CARDITIS Sources: Acute Rheumatic Fever - StatPearls - NCBI Bookshelf - https://www.ncbi.nlm.nih.gov/books/NBK459263/ · ICPC-3 (WONCA International Classification of Primary Care, 3rd edition) class KD02.00 - condition scope only, no dose · No dose - referral pathway, no medicine given in primary care Review status: REVIEWED against No dose - referral pathway, no medicine given in primary care, Egyptian National Drug Formulary - Antimicrobial 2023 (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (9) - Up to a third of ARF patients have no memory of the sore throat that came before it - The preceding strep throat typically brings fever, throat pain, headache, and chills [chills · fever · headache · sore throat] - Abdominal pain, nausea, and vomiting can accompany the preceding infection, especially in young children [abdominal pain · nausea · vomiting] - Fever, chills, and fatigue are the most common general symptoms of ARF [chills · fatigue · fever] - Joint pain is usually migratory, moving between large joints such as the knee, ankle, or wrist [joint pain] - Joint pain or swelling is often the first thing ARF shows, seen in 60% to 80% of cases [joint pain] - Sydenham chorea shows up as jerky, involuntary movements affecting the face, hands, or feet [chorea · involuntary movements] - Chorea movements are more pronounced on one side and stop during sleep [chorea] - Agitation, anxiety, or inappropriate laughing or crying may accompany the chorea [anxiety · chorea · irritability] SIGNS - what you find (7) - A fast heart rate or a new heart murmur are the most common exam findings of carditis [heart murmur · tachycardia] - Carditis hits the pericardium, epicardium, myocardium, and endocardium together, roughly 2 to 3 weeks after the strep infection - Mitral regurgitation is usually the first sign of valve involvement, producing a loud holosystolic murmur best heard at the apex, radiating to the axilla [heart murmur] - Aortic valve damage produces a diastolic murmur at the base of the heart, louder when the patient leans forward [heart murmur] - Firm, painless nodules over the extensor surfaces of joints occur in under 10% of ARF and track with severe carditis - Erythema marginatum is a fleeting pink ring-shaped rash on the trunk and limbs, sparing the face, in under 6% of cases [rash · redness] - The milkmaid's grip sign, an inability to hold a steady squeeze on the examiner's fingers, is characteristic of Sydenham chorea [chorea] TESTS (11) - Initial diagnosis needs 2 major criteria, or 1 major plus 2 minor criteria, under the Jones Criteria - A recurrent episode can also be diagnosed with 3 minor criteria alone - Sydenham chorea or indolent carditis appearing months after strep infection allows a presumptive diagnosis without the Jones criteria - NAAT testing for GAS returns a result in under an hour and is highly sensitive - Rapid antigen tests may be under 90% sensitive, so a backup throat culture is recommended when negative - ASO or anti-DNase B titers rise 2 to 3 weeks after a strep infection - A 2-fold or greater rise in antibody titer between paired samples counts as positive - All ARF patients should get a chest x-ray, ECG, and echocardiogram to assess the heart - Chest imaging may show an enlarged heart and pulmonary oedema - PR interval prolongation is the most common ECG finding and must be judged against age-based norms - About 10.8% of ARF patients have subclinical carditis found only on echocardiogram IF NOT THIS - what else fits (9) - Poststreptococcal reactive arthritis is a differential for the joint symptoms - Septic arthritis needs to be excluded when a joint is inflamed - Lyme disease is a differential for the migratory joint pain - Infective endocarditis is an important differential for the cardiac findings - Viral myocarditis can mimic the carditis of ARF - PANDAS is a differential for the chorea-like movements - Tourette syndrome and tardive dyskinesia are differentials for the movement disorder - Scarlet fever is a differential for the rash of ARF - Systemic lupus erythematosus is among the systemic-illness differentials Source StatPearls "Acute Rheumatic Fever" - disease-level clinical article Status traced to the source above 1. NO DRUG THERAPY IN PRIMARY CARE (REFERRAL & ADVICE) [1st line] Adult Active rheumatic fever with carditis needs hospital-level monitoring (echocardiography, watching for heart failure); the GP recognises the picture, starts antibiotic treatment of the streptococcal trigger, and refers urgently rather than managing carditis alone. - Refer, with advice Peds Children follow the same pathway: recognise and refer. No primary-care medicine is implied. Source No dose - referral pathway, no medicine given in primary care Why Active rheumatic fever with carditis needs hospital-level monitoring (echocardiography, watching for heart failure); the GP recognises the picture, starts antibiotic treatment of the streptococcal trigger, and refers urgently rather than managing carditis alone. Caution Breathlessness, tachycardia out of proportion to fever, or a new murmur indicates carditis severe enough to need same-day hospital assessment. No medicine is prescribed for this in primary care - this entry is for recognition and referral. Anything given is decided by the service it is referred to. 2. PENICILLIN G BENZATHINE [1st line] Adult IM: 1.2 million units once every 21 to 28 days - Duration depends on risk factors and presence of valvular heart disease Peds ≤27 kg: 600,000 units every 3 to 4 weeks. >27 kg: 1.2 million units every 3 to 4 weeks. Source Egyptian National Drug Formulary - Antimicrobial 2023 Why Intramuscular penicillin G benzathine provides secondary prophylaxis against recurrent Group A streptococcal infection to prevent recurrent rheumatic fever and progressive cardiac damage. Caution Hypersensitivity to penicillin(s) or any component of the formulation Do not administer IV, intra-arterially, or SubQ. inadvertent IV administration has resulted in thrombosis, severe neurovascular damage, cardiac arrest, and death. Egypt HAYA BENZ-R 1.2 M.I.U. VIAL FOR I.M INJ. SEDICO > HAYA PHARM-EGYPT 5.06 EGP PENICID LA 1 200 000 UNITS VIAL CID 6.50 EGP BENZACILLIN 1.2 M.I.U.FOR I.M.INJ VIAL. EL NASR 7.00 EGP RETARPEN 1.2 M.I.U. VIAL SANDOZ > OCTO... 10.50 EGP LASTIPEN 1 200 000 IU VIAL MISR 12.00 EGP BENZABIOTIC 1.2 M.I.U. I.M. VIAL. SEDICO 16.00 EGP DEPO-PEN 1.2 MIU VIAL. MUP 25.00 EGP PENCILONG (PENCITARD) 1200000 I.U./VIAL NCPC NORTH BEST CO > ACDIMA INTE... 25.00 EGP Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)